Maternal Newborn Nursing Test Neonatal Assessment and Immediate Care

Question 1

A nurse assesses a newborn at 1 minute and assigns an Apgar score.
The infant has a heart rate of 98 bpm, weak cry, some flexion of extremities, grimace to stimulation, and a pink body with blue extremities.
What is the Apgar score?

Accepted Answer

6

Answer

7

Answer

5

Answer

8

Question 2

Which assessment finding in a newborn at 24 hours of life requires immediate provider notification?

Accepted Answer

Respiratory rate of 68 breaths per minute with grunting

Answer

Respiratory rate of 40 breaths per minute

Answer

Acrocyanosis of the hands and feet

Answer

Passage of meconium stool

Question 3

A nurse notes a newborn's axillary temperature is 36.1°C (97°F) at 2 hours of life. What is the priority intervention?

Accepted Answer

Place the newborn under a radiant warmer and reassess in 30 minutes

Answer

Administer warm IV fluids

Answer

Notify the provider immediately for sepsis workup

Answer

Encourage skin-to-skin contact with the mother only

Question 4

When assessing the anterior fontanel of a newborn, which finding is abnormal?

Accepted Answer

Bulging and tense fontanel in a quiet, non-crying infant

Answer

Soft and flat fontanel

Answer

Fontanel that slightly bulges when the infant cries

Answer

Diamond-shaped fontanel measuring 2 × 2 cm

Question 5

Which reflex is assessed by stroking the lateral aspect of the sole of the newborn's foot from heel to toe, resulting in dorsiflexion of the big toe and fanning of other toes?

Accepted Answer

Babinski reflex

Answer

Stepping reflex

Answer

Moro reflex

Answer

Rooting reflex

Question 6

A nurse assesses a newborn's blood glucose 30 minutes after birth. The result is 38 mg/dL. What should the nurse do first?

Accepted Answer

Initiate early feeding (breast or formula) and recheck glucose in 30–60 minutes

Answer

Administer IV dextrose immediately

Answer

Report the finding to the provider and await orders before acting

Answer

Document the finding as normal and continue routine care